Watching Americans debate health care reform throughout 2009 called to mind the old Irish joke.
Lost in rural Ireland, the tourist asks a local, "How do I get to Ballygambema?" "Well," replies the local, "I wouldn't start from here."
"Here" is a system that leaves about 45 million people without insurance, millions more underinsured, insurance and pharmaceutical companies making huge profits - a system that costs the country 16 per cent of its annual national income for aggregate health outcomes no better than in countries such as Canada, whose systems cost much less.
Put another way, there are a bunch of good reasons why no other country in the world copies the U.S. health-care system, or would want to reform its system by using the "here" of U.S. health care. It's too costly and ineffective, although the system works just fine for those with first-rate insurance. (And critiquing the U.S. system can be dangerous for Canadians, since it can lead to a hear-no-evil, speak-no-evil attitude toward our own system.)
Free-market principles are great for many products. Health care isn't one of them, in part because the balance of information between consumer/patient and doctor/hospital provided is so uneven. Moreover, access to health care shouldn't be a commodity or a service, but a right, the definition and protection of which will necessarily spark debates in democratic societies.
Starting from the "here" of U.S. health care, pre-Obama, produced a year-long struggle that is now in the Senate, where the Democratic leadership believes it has wheeled and cajoled, bargained and bought off enough senators to get the 60 required to blunt a Republican filibuster.
After Senate action, a reconciliation process must begin between the Senate bill and the one adopted in November by the House of Representatives. Who knows how long this will take? The Senate bill ran 2,074 pages (yes, you read that correctly) before an amendment of 380 pages was added the other day to secure the support of a holdout Democrat from the great state of Nebraska.
President Barack Obama had wanted a bill to sign before the summer recess. Now, he'll be lucky to receive one in January. What he eventually signs will be removed from the high hopes he initially offered for health-care reform.
Health care is emotive in every democratic country. Health-care systems everywhere are complicated, none more so than in the United States. Health care touches everyone and eats up a big chunk of every country's national income. Reforming it, therefore, is always going to be hard political work.
Having said that, the laborious, fiercely partisan, year-long U.S. debate begs more fundamental questions of the kind that will hang over that country and the world in 2010 and beyond, including whether the United States can properly govern itself, in the sense of grappling with the myriad of profound, structural challenges that the country faces.
If the answer is yes, that the Great Republic can summon the political will and move its governmental system to grapple with these huge challenges, then those of us dependent on good government in that country will breathe a sigh of relief. If, however, Americans continue to govern themselves badly, with their political system unable to get a grip on major problems, then we all suffer.
Such is the burden of great power leadership. If Canada screws things up, few other countries will care, and none will be seriously damaged. If the Americans screw up their policies, people outside the country will be affected, directly or indirectly, none more than those who live beside them.
Post-Copenhagen, the world's climate-change fate hangs more than anywhere else in the U.S. Senate. If the United States fails to act in 2010, or adopts diluted legislation, the incentive for others to move will wane. If the Senate does move forcefully, it will give Mr. Obama a powerful platform from which to budge and nudge other countries, to say nothing of eventually bringing down emissions from the world's second-largest emitter (after China).
Of equal consequence is how the U.S. political system will deal with its huge deficits and a national debt ($9-trillion forecast in the next decade) that requires massive borrowing and, in turn, introduces uncertainties and instabilities in the world economy.
The list of challenges goes on: Social Security, immigration, trade deficits, two wars. How or if the U.S. tackles them will be among the world's most consequential questions next year, and beyond.